AF

Question 1

Classifications of AF

Answer 1

Paroxysmal: 48hrs- 7days - self termination
Persistent: >7days -> longstanding persistent: >/= 1 year and rhythm control is decided
Permanent: accepted by patient, no rhythm control

Question 2

Presentation of atrial flutter

Answer 2

2:1 AV block and regular ventricular rate of 150bpm

Ventricular rate 150bpm with narrow QRS complexes

Question 3

Mng of atrial flutter

Answer 3

Reverts with low energy DV or with overdrive pacing
Often insensitive to antiarrhythmic drugs

Then rhythm rate control and ppx VTE
If recurrent consider catheter ablation

Question 4

How to calculate ventricular rate on ECG

Answer 4

Same as HR

So if regular: 300/large boxes between QRS complexes
If irregular: in a 6 second strip multiple number of QRS complexes by 10

Question 5

How to calculate atrial rate on ECG

Answer 5

If consisten PP intervals: 300/ large boxes between P waves
If irregular: 6 second strip = number of P waves x 10

Question 6

Comorbids and precipitating factors for AF

Answer 6

HF
HTN
OSA and other lung diseases
Hyperthyroidism
Surgical stress
PE
Myocardial ischemia
Valvular heart disease
Sepsis
Obesity
ETOH

Question 7

Principles of AF management

Answer 7

ID comorbids and precipitating factors
Prevent thromboembolic events
Mng arrhythmia = rate and rhythm control

Question 8

Thromboemoblic risk mng in AF

Answer 8

Calculate CHADSVASC and HASBLED score

Start anticoags if appripriate
Valvular = Warfarin
Non valvular= DOAC

Question 9

What does Arrhythmia mng in AF depend upon

Answer 9

Hemodynamics
Duration of episode
resources available and pt preference
VTE risk

Question 10

Options for inital arrhythmia mng in AF and their indications

Answer 10

1. Rhythm/ cardioversion- symptomatic, decreased LVEF, AF <12mo, rate control not effective
2. Rate -
   Prevent detoration, increased ventricular rate, failed rhythm control

Question 11

Options for Rhythm control in AF

Answer 11

1. Electrical - higher success, increase success if: biphasic, AP pad position. Done in both stable and unstable patients
2. Pharmacological: 50% success. Choice depends on CAD and LVEF

Question 12

Pharmacological rhythm control options in acute AF management

Answer 12

Flecanide - LVEF >40% and no CAD
Amiodarone - LVEF <40% and CAD

Question 13

How to manage unstable AF

Answer 13

Immediate DC electircal cardioversion

Question 14

How to manage stable AF

Answer 14

If <48 hours: can either do rate control or rhythm control with electrical/pharm cardioversion plus anticoags

If >48hours: R/O left atrial thrombus with TOE or anticoagulate for minimum of 3 weeks -> then caridoversion with anticoags started at time of cardioversion and continued for a minimum of 4 weeks
IF can’t r/o thrombus or hasn’t been anticoag then rate control

Question 15

Options for rate control in AF

Answer 15

Rarely used. Monitor BP if used.

Metoprolol tartrate, osmolol, verapamil

Question 16

Long term rhythm control in AF

Answer 16

1. Catheter ablation - preferred to be done <12mo after dx. Decreased success in longstanding AF, atrial dilation, untreated RFs

2.Antiarrhhtymic- sotalol if noirmal EF but CAD
Flecanide if no CAD but reduced EF

Question 17

Long term Rate control in AF

Answer 17

1. Beta blockers: atenolol, metoprolol. If LVEF <40 use- carvedilol, bisoprolol, nebivolol
2. NDP CCBS: diltiazem, verapamil
   CI in lvef <40
3. Digoxin
4. Amiodarone